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oPa�'"' c SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SITE e: 600 East Main Street, Stockton, CA 95202-3029 MITIGATION Telephone: (209)468-3454 Fax: (209)468-3433 Web:www.sigov.org/ehd nr.ULNIT IV 9�lFORa` WELL PERMIT APPLICATION rl it UEF/ Ve® NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED MAY p ,/�', Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. This application is made in compliance-wi"n Joaquin County Development Title,chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department Well Location E. Hard; wo, Cross Streety, holdtr (r.«f t Avc. City Zip 95?CS P jI ( 0z Property ""�YICES Owner Gk;pa Qro p4f4-,e5 1,L C- Address 10 god Il City,ye-wi- $teoV1 Zip gZlrbL Phone# C-57 Contractor V dr W Address I SOL* Dyek Cvea k- D.-. City S+o cle �w, Zip q5715' Lic# 7 t e 90 y Phone Consultant/SubCntr lr10-4 Zt.ro Address 171Lf /tomft, - City 1✓Ss.6144— Lic# Phone 8';Q--98.1r21?" GIS Coordinates:X Y Township Range Section WORK TO BE PERFORMED: ❑NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) DESTRUCTION(CHOOSE TYPE BELOW) ❑SOIL BORING# N OVER-BORE DIAMETER 6'" (AA W 1 - ❑WELL# [9PRESSURE GROUT „Awl nn wy n w S ❑'OTHER GROUT SPECIFICATIONS A ❑EXPLOSIVES DETONATING CARD (,0�M E,'O T C,w"I- TYPE SNnp«cFtd v�i1S {u �1! ovt✓dr Ikd. Ndn- 1r•+rw�{�el w�llf 1�t vneCSvX. A✓tl✓f� TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS 71 MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: ❑EXTRACTION ❑AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING:❑STEEL ❑PVC ❑ OTHER ❑VAPOR ❑MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED❑AUGERS❑HOSE ❑AIR SPARGE/OZONE ❑PUSH POINT(GP OR CPT)_GROUT SEAL PUMPED:❑Yes ❑No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') ❑SOIL BORING ❑HAND AUGER GROUT SPECIFICATIONS ❑OTHER: ❑OTHER: APPROX.BORING DEPTH ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE CONDUCTOR CASING PROPOSED (if YES,list specifications in comment section) COMMENTS: NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS I hereby certify that I have prepared this application and that the work will be done I accordance with San Joaquin County Ordinances,Rules and Regulations,and allapplicableCalifornia Laws. Signed Title/Company 54-ot Ff- Lreo I vy r S � /Ir r o.^'j 14!-o A'C-��t �S Print Name Date DEPARTMENT USE ONLY SITE MAP IN UNIT IV FILE,ADDRESS: 7 r9 oo WORK PLAN DATED ` l iq it APPLICATION ACCEPTED BY DATE ISSUED 5-115;_111 AREA GROUT INSPECTION BY l < tit/ FINAL INSPECTION BY DATE lC I DESTRUCTION INSPECTION BY DATE S IDI it COMMENTS/CONDITIONS: Al tj- 1 1,Ja� fit,-, c_Q (nJt7��1(-), Ovlic�,r�S ACCOUNTING ONLY: AID# FAC# PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE PERMIT/SERVICE# INVOICE z Cl 0 z S`X 17,2- * 61 a• ori 7_arC2_'t 6f s f f f/I §R# ( Z.4`S 6 C-57 WC -WAIVER C57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC EHD 29-01 10/28/09 WELL PERMIT APP Z�o3 366 $� 366.«